Acute Pelvic Pain

Key Points

• Acute pelvic pain can be related to multiple organ systems.

• Gynecologic pain typically includes pregnancy complications, infection, and ovarian cysts.

• Clinicians should have a low threshold for treating pelvic inflammatory disease because of the potential for long-term complications.

Acute lower abdominal pain can be caused by multiple organ systems. Urinary tract infections (UTIs) are often associated with pain over the bladder related to dysuria, frequency, and urgency of urination. Gastrointestinal causes of lower abdominal pain include acute appendicitis, diverticu-litis, irritable bowel syndrome, and ischemic bowel.

Gynecologic causes of acute pelvic pain are usually related to complications of pregnancy, infections, or ovarian pathology. Ectopic pregnancy is a serious cause of acute pain in the context of an early pregnancy. Ectopic pregnancy should be suspected when the quantitive human chorionic gonadotropin (hCG) level does not increase appropriately, or if hCG level is greater than 1500 mIU and transvaginal ultrasound does not show an intrauterine gestational sac. The dilation of the fallopian tube caused by the growing embryo is the etiology of the pain. Emergent treatment with either medication or surgery is necessary to prevent rupture of the tube. Ectopic pregnancy is usually diagnosed by ultrasound. Treatment of an ectopic pregnancy can be surgical or medical. Single-dose methotrexate is the most frequently used regimen, 50 mg/m2 of body surface intramuscularly, but no studies have compared efficacy between single-dose and multidose therapies (Lozeau and Potter, 2005). Degenerating fibroid tumors may also cause pain as a result of ischemia during pregnancy, usually in the second trimester.

Pelvic infections such as acute cervicitis and pelvic inflammatory disease (PID) can cause pain associated commonly with abnormal vaginal discharge and systemic symptoms of infection. On examination, most women will have a purulent cervicitis, a tender uterus, and cervical motion tenderness. Both outpatient and inpatient treatment options are available from the CDC STI treatment guidelines, at www.cdc.gov (2006). Outpatient treatment of PID usually includes intramuscular (IM) ceftriaxone and doxycycline for 10 days to cover both Neisseria gonorrhoeae and Chlamydia. Untreated PID can lead to an abscess or scarring that can cause infertility. Clinical diagnosis of PID has a positive predictive value of 65% to 90% (BAASH, 2005). Therefore, clinicians should have a low threshold for treating women with suspected PID.

Ovarian cysts are common and often cause no pain. When cysts rupture, however, women will experience acute pelvic pain from peritoneal irritation. Large ovarian cysts are more likely to undergo torsion and can cause pain from ischemia.

KEY TREATMENT

Medical and surgical treatments for ectopic pregnancy are equivalent when patient selection is appropriate (Lozeau and Potter, 2005) (SOR: B).

Single-dose methotrexate is the most common regimen (50 mg/ m2 body surface IM) for ectopic pregnancy (Lozeau and Potter, 2005) (SOR: C).

Clinicians should have a low threshold for treating women with suspected PID because of potential long-term consequences (BAASH, 2005) (SOR: C).

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